Get Medical Records/images Release Form - The Chiropractic Center Of ...

Filling out the Medical Records/images Release Form is an essential step in obtaining your health records from The Chiropractic Center. This guide provides you with clear instructions to assist you throughout the process, ensuring that your information is accurately submitted online.

Follow the steps to complete your release form efficiently.

1. Click the ‘Get Form’ button to access the Medical Records/images Release Form and open it for editing.
2. Begin by entering your personal information. Fill in your full name, date of birth, and social security number in the designated fields.
3. Provide contact details by entering your daytime phone number and fax number. This information is crucial for any follow-up regarding your request.
4. Indicate the images you require by specifying the body part(s) related to your request. This helps ensure that the correct records are sent to you.
5. Approximate the dates when the images were taken and initially confirm the section by filling in the necessary details.
6. You may also specify any restrictions on the release of medical information by filling out the relevant section. Ensure you include necessary context to guide the request.
7. Read the validation period for your authorization. It is valid for 90 days from the date of your signature, which you will be required to initial.
8. Select how you would like to receive your records: picking up in person, having someone else pick them up, mailing, or faxing. Provide details of the person who will pick up the records, if applicable.
9. Specify the mailing address if your records are to be sent via mail. Fill in the information for the recipient, including the street address, city, state, and zip code.
10. Finally, sign the form at the bottom and print your name alongside it. Ensure you include the date of signing.
11. After completing all fields correctly, ensure to save any changes, download the form if needed, and share it with the required recipient.

Complete your documents online today to ensure timely access to your important medical information.